2013 European Guideline on the Management of Proctitis

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2013 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens Henry JC de Vries, Adele Zingoni, John A White, Jonathan DC Ross and Alexander Kreuter Int J STD AIDS 2014 25: 465 originally published online 18 December 2013 DOI: 10.1177/0956462413516100

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Henry JC de Vries1,2,3,4, Adele Zingoni5, John A White6, Jonathan DC Ross7 and Alexander Kreuter8

Summary Proctitis is defined as an inflammatory syndrome of the distal 10–12 cm of the anal canal, also called the rectum. Infectious proctitis can be sexually transmitted via genital-anal mucosal contact, but some also via mutual masturbation. N. gonorrhoeae, C. trachomatis (including lymphogranuloma venereum), Herpes Simplex Virus and T. pallidum are the most common sexually transmitted anorectal pathogens. Shigellosis can be transferred via oral-anal contact and may lead to proctocolitis or enteritis. Although most studies on these infections have concentrated on men who have sex with men (MSM), a significant proportion of women have anal intercourse and therefore may also be at risk. A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available. The symptoms of proctitis include anorectal itching, pain, cramps (tenesmus) and discharge in and around the anal canal. Asymptomatic proctitis occurs frequently and can only be detected by laboratory tests. The majority of rectal chlamydia and gonococcal infections are asymptomatic. Therefore when there is a history of receptive anal contact, exclusion of anorectal infections is generally indicated as part of standard screening for sexually transmitted infections (STIs). Condom use does not guarantee protection from bacterial and protozoan STIs, which are often spread without penile penetration.

Keywords HIV, AIDS, sexually transmitted infections, proctitis, proctocolitis, enteritis, men who have sex with men, MSM, homosexual, lymphogranuloma venereum, bacterial, disease, Chlamydia trachomatis, Treponema pallidum, Neisseria gonorrhoeae, herpes simplex virus, guideline

Date received: 30 August 2013; accepted: 21 October 2013

1STI outpatient clinic, Cluster Infectious Diseases, Health Service Amsterdam, Amsterdam, The Netherlands 2Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands 3Centre for Infectious Diseases and Immunology Amsterdam (CINIMA), Guideline editor Amsterdam, The Netherlands 4Centre for Infectious Disease Control, National Institute of Public Prof Jonathan Ross, University Hospital Birmingham, Health and the Environment, Bilthoven, The Netherlands UK 5Department of Biomedical Sciences and Human Oncology, Dermatologic Clinic, University of Turin, Turin, Italy 6 IUSTI European STD Guidelines Editorial Board Department of Genitourinary Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Dr Keith Radcliﬀe - Editor-in-Chief, Dr Karen 7Sexual Health Clinic – University Hospitals Birmingham NHS Foundation Babayan, Dr Gilbert Donders, Dr Michel Janier, Dr Trust, Whittall Street Clinic, Birmingham, UK Jorgen Skov Jensen, Prof. Harald Moi, Dr Raj Patel, 8Department of Dermatology, Venereology, and Allergology, HELIOS St. Prof Jonathan Ross, Dr Jackie Sherrard, Dr Magnus Elisabeth Hospital Oberhausen, Germany Unemo, Dr Willem van der Meijden, Dr Simon Corresponding author: Barton, Dr Lali Khotenashvili, Dr Marita van de HJC de Vries, STI Outpatient Clinic, Cluster Infectious Diseases, Health Laar, Prof. Martino Neumann, Prof Mario Poljak, Dr Service Amsterdam, Amsterdam, The Netherlands. Angela Robinson. Email: [email protected] NICE has accredited the process used by BASHH to produce its European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. Accreditation is valid for 5 years from 2013. More information on accreditation can be viewed at www.nice.org.uk/accreditation

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What is new in this updated guideline? in women via a genital infection due to the proximity of the vagina. Intestinal infections can be acquired through The majority of rectal chlamydia and gonococcal infec- oral-anal sexual contact. These infections may lead to tions are asymptomatic. It is therefore important to symptomatic proctitis, proctocolitis or enteritis. (Box 1) exclude both infections (preferably via a nucleic acid Though it is likely that M. genitalium infects the amplification test [NAAT]) in all who report receptive rectum,5 it is unclear if it contributes to clinical syn- anal sexual contact within the past 6 months, even in dromes.6 T. vaginalis is rarely found in the rectum. the absence of anorectal symptoms. HIV-related morbidity and mortality have consider- Although not approved by the manufacturers and ably decreased since the introduction of highly active regulating bodies like the FDA, currently available antiretroviral therapy (HAART).7 As a result of the sig- NAATs are the tests of choice for the detection of chla- nificantly prolonged life span of HIV-positive patients in mydial and gonococcal infections at the rectal site. the HAART era, non-AIDS defining malignancies, such A patient-collected rectal swab to exclude gonor- as anal carcinoma, are observed in excess in HIV-posi- rhoea and chlamydia infections via NAAT is a feasible, tive MSM. Anal carcinoma and its precursor lesions, valid and acceptable alternative for sexually trans- anal intraepithelial neoplasia (AIN), are caused by mitted infection (STI) clinic visitors. high-risk human papillomavirus (HPV). HPV-related With the emergence of multidrug-resistant (MDR- disease is not discussed further in this guideline. For Ng) and extremely multidrug-resistant gonorrhoea recommendations please consult specific guidelines.8 strains (XDR-Ng), culture of N. gonorrhoeae for surveillance purposes has become increasingly important. Clinical features of proctitis, proctocolitis Rectal microscopy for syndromic management and enteritis increases the proportion of men treated for gonorrhoea at their first attendance to an STI outpatient clinic, but Symptoms (history) confirmation by additional NAAT or culture tests is required. (a) In patients with acute proctitis (inflammation of Anorectal lymphogranuloma venereum (LGV) gen- the rectum): erally is a symptomatic infection, although asymptom- . Mucopurulent anal discharge; atic anorectal LGV does occur. . Anorectal bleeding; LGV should be considered in MSM with acute proc- . Constipation; titis as well as those with suspected chronic inflamma- . A sensation of rectal fullness or of incomplete tory bowel disease defaecation; . Tenesmus. Aetiology and transmission Anorectal LGV generally is a symptomatic infection, Anal sexual intercourse is widely practiced both among although asymptomatic anorectal LGV does occur9 heterosexuals but especially in MSM.1 As a conse- (level 1a, grade B, see Appendix). quence rectal infections should be routinely excluded In patients with mild proctitis (and in those with when MSM are screened for STIs.2 In the absence of chronic proctitis), there may only be: receptive anal intercourse, N. gonorrhoeae can still be transmitted easily to the anal canal via fingering, and . A history of mucus streaking of the stool;

Box 1. Sexually transmissible causes of proctitis, proctocolitis and enteritis.

Causes of distal proctitis Causes of proctocolitis Causes of enteritis

Neisseria gonorrhoeae Shigella spp. Giardia duodenalis Chlamydia trachomatis: Campylobacter spp. Cryptosporidium spp. Genotypes D-K Salmonella spp. Microsporidium ssp.a Genotypes L1–3 (LGV) Escherichia coli Hepatitis A Treponema pallidum Entamoeba histolytica Herpes simplex virus Cryptosporidium spp. Cytomegalovirusa

LGV: lymphogranuloma venereum. aIn severely immunocompromised patients (in the context of HIV infection with low CD4þ T-cell counts).3 Sometimes in immunocompetent patients (especially in relation to inflammatory bowel syndromes). Note: It is important to note that several STIs may co-exist.4

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. Constipation; (c) Enteritis: . Sometimes a feeling of incomplete defaecation. The rectal mucosa appears normal unless there is concurrent infection with organisms causing The presence of the additional features mentioned proctitis. above (i.e. discharge, bleeding, tenesmus) suggests more severe proctitis. Diagnostic tests for the pathogens causing (b) In patients with acute proctocolitis (inflammation proctitis, proctocolitis and enteritis of the rectum and colon): Rectal gonorrhoea and chlamydial infections . Small volume diarrhoea; . Bloody stool; The majority of rectal chlamydia and gonococcal infec- . Lower abdominal pain; tions are asymptomatic.14,15 It is therefore important to . Abdominal tenderness; exclude both infections (preferably via an NAAT) in all . Anorectal bleeding; who report receptive anal sexual contact within the past . Sensation of incomplete defaecation. 6 months, even in the absence of anorectal symptoms. (c) In patients with enteritis (inflammation of the small Although not approved by the manufacturers and intestine): regulating bodies like the Food and Drug . Large volume, watery diarrhoea; Administration (FDA) in the United States, currently . Bloody stool; available NAATs are the tests of choice for the detec- . Mid-abdominal cramps; tion of chlamydial and gonococcal infections at the . Nausea with or without vomiting; rectal site16 (level IIa, grade B). . Malaise; With the appropriate instructions, a patient-col- . Fever; lected rectal swab to exclude gonorrhoea and chla- . Weight loss. mydia infections with the use of a dual NAAT is a feasible, valid and acceptable alternative for STI clinic In HIV-infected MSM engaging in oro-anal sex visitors17 (level IIa, grade B). (rimming) with signs of enteritis, Shigellosis especially should be considered.10 Rectal gonorrhoea. With the emergence of MDR-Ng and XDR-Ng, culture of N. gonorrhoeae for surveillance purposes becomes increasingly important.18 Signs (findings at clinical examination) Material for culture for N. gonorrhoeae should be obtained either by the passage of a swab through the (a) Proctitis (that is proctitis confined to the distal anal canal into the distal rectum or under direct vision 12–15 cm of the rectum): via an proctoscope19 (level III, grade C). . Mucopus in lumen of rectum; Direct microscopy of slides of rectal swabs by Gram . Loss of normal vascular pattern (although note stain analysis may increase the proportion of men trea- that the vascular pattern may not be apparent ted for gonorrhoea at their first attendance to an STI in the distal 10 cm of the normal rectum); outpatient clinic.20 Gram-negative diplococci may be . Mucosal oedema; seen within the cytoplasm of neutrophilic granulocytes, . Contact bleeding; permitting a presumptive diagnosis of rectal gonor- . Sometimes ulceration; rhoea. Since the sensitivity is suboptimal, confirmation . LGV and syphilis may cause an inflammatory, by additional NAAT or culture tests is required (level sometimes ulcerated, tumorous infiltrate in the IIb, grade B). distal rectum or anal canal.11,12 Rectal. chlamydial infection LGV should be considered in MSM with suspected chronic inflammatory bowel disease, since the (a) By biovar trachomatis (genotypes D-K): clinical presentation and histopathologic findings of C. trachomatis genotypes D-K infect epithelial cells LGV proctitis are similar to other causes of granuloma- of mucosal surfaces and the diagnosis of rectal tous proctitis such as Crohn’s disease13 (grade IV, chlamydia is usually made by testing rectal material level C). with a NAAT, collected as for gonorrhoea (see above).21 However, the US FDA has not yet (b) Proctocolitis: approved testing of rectal swabs, and protocols As for proctitis, the inflammatory changes extend for testing rectal specimens are not included in beyond the rectosigmoid junction. the manufacturers’ kit inserts.

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(b) By biovar LGV (genotypes L1–3): or trichrome may reveal trophozoites with ingested Rectal specimens from MSM that test positive for erythrocytes which is pathognomonic for Entamoeba C. trachomatis by NAAT should be characterized histolytica infection. further (genotyping for LGV) (level IIa, grade B). Cysts of the protozoan may be found in diar- Further testing of C. trachomatis-positive NAAT rhoeal stools or in formed faeces. It is important material for LGV DNA is possible in specific to differentiate between E. histolytica and the laboratories in many European countries (contact non-pathogenic amoeba E. dispar that resembles E. his- European Surveillance for Sexually Transmitted tolytica morphologically under the microscope. This Infections [ESSTI]; Website: www.essti.org).22,23 differentiaton is usually done by using a molecular If molecular LGV characterization is unavailable, a test NAAT. Chlamydia IgA-specific antibody test can be an alternative choice to make a presumptive diagnosis of Cytomegalovirus infection LGV.24 LGV is likely in case of an elevated antibody titre (far outside the normal ranges) in combination The triad of mononucleosis-like illness with rectal with a confirmed rectal C. trachomatis infection. bleeding shortly after unprotected anal intercourse is pathognomonic for sexually transmitted cytomegalovirus (CMV) proctitis.28 Suggestive findings on ano- Anorectal syphilis scopy or sigmoidoscopy include rectal mucositis and ulceration. CMV serology and biopsy, including Dark-field microscopy for treponemes or a (multiplex) CMV immunohistochemistry, are confirmatory. The NAAT for Treponema pallidum DNA from exudate finding of typical intranuclear inclusion bodies in from an ulcerated lesion may be used25 (level IIa, grade B). rectal or colonic biopsies is considered diagnostic. Specific serological tests such as an immunoglobulin G and/or M (IgM and/or IgM) antitreponemal anti- Giardiasis body enzyme immunoassay or chemiluminescence immunoassay with confirmation by another specific Fluid stool samples should be microscopically exam- treponemal antibody and a raised titre cardiolipin anti- ined for the trophozoites and cysts of Giardia lamblia. body test support a diagnosis of syphilitic proctitis in Repeated examinations (at least three) are often neces- the presence of symptoms/signs of proctitis and nega- sary before a diagnosis is made. tive tests for other pathogens. Enzyme immunoassays, direct immunofluorescence tests and specific NAAT for the detection of Giardia Anorectal herpes simplex virus infection infection are increasingly available and aiding in diagnosis of Giardia infection.29 A herpes simplex virus (HSV) NAAT such as polymerase chain reaction (PCR) should be used routinely, as Cryptosporidiosis and microsporidiosis this is a more sensitive test than culture26 (level IIa, grade B). Special stool preparations (in consultation with the local microbiologist) are required to diagnose crypto- Bacterial infections causing proctocolitis sporidiosis and microsporidiosis. Faecal samples are examined after staining for the oocysts of these Culture of Shigella spp., Salmonella spp. or protozoans. Campylobacter spp. from faecal samples yields the diag- The discovery of various stages of the life cycle of the nosis. Sometimes repeated examinations are necessary organism within the enterocytes on histological examin- before a diagnosis is made. Molecular tests for bacterial ation of jejunal, colonic or rectal biopsy is diagnostic. pathogens are becoming more widespread and have Enzyme immunoassays, direct immunofluorescence improved sensitivity over culture, although antimicrobial tests and NAAT for the detection of cryptosporidial susceptibility testing still requires a positive culture.27 antigens/ DNA have a high sensitivity/specificity and are commercially available29 (level Ib, grade A). Amoebiasis Non-specific proctitis Microscopic examination for the trophozoites of Entamoeba histolytica of diarrhoeal stool specimens, In some patients with symptoms and signs of a distal rectal exudate or scrapings from rectal ulcers should proctitis, N. gonorrhoeae and C. trachomatis cannot be be attempted. Direct wet stool examination/microscopy detected. These individuals are said to have non-specific of freshly obtained (bloody) samples stained with eosin proctitis.

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If no infectious cause can be found and the proctitis the Management of Lymphogranuloma Venereum: persists after empiric therapy, the patient should be http://www.iusti.org/regions/Europe/euroguidelines. referred to a gastrointestinal specialist to exclude htm). other causes of proctitis such as Crohns’ disease. Anorectal syphilis Management Patient management should follow that recom- Information, explanation and advice for the patient. In all mended for early syphilis infection (see IUSTI: 2008 cases of proctitis (symptomatic or asymptomatic) European Guidelines on the Management of Syphilis: caused by a sexually transmitted pathogen, patients http://www.iusti.org/regions/Europe/euroguidelines. should be given a detailed explanation of their con- htm). dition with particular emphasis on the long-term implications for the health of themselves and their Anorectal HSV infection partner(s). This should be reinforced by giving clear and accurate written information. Regular sexual Patient management should follow that recommended health checks should be offered to those individuals for anogenital HSV infection (see 2010 European who have frequent changes of sexual partners. guideline for the management of genital herpes: In the prevention of ongoing sexual transmission of http://www.iusti.org/regions/Europe/euroguidelines. the bacterial pathogens the following recommendations htm). should be communicated30 (level III, grade C): Shigella, salmonella and campylobacter infections . wash hands after using toilet, before preparing or eating food and after sexual activity; Therapy: Antimicrobial therapy is often unnecessary in . avoid anal sex, oral-anal sex (rimming), coprophagia the treatment of shigella, salmonella and campylobacter (scat) whilst symptomatic and until test for infection infections. If indicated (for example in those with bloody shows clearance; diarrhoea, and in individuals with AIDS or sickle-cell . use of condoms, gloves, dental dams during sex; the disease in whom infection tends to be more severe and use of gloves for ‘‘fisting’’ should be encouraged; sometimes fatal), the choice of drug is best to be advised . avoid sharing douching materials, enemas and sex toys; by a microbiologist informed of the pattern of anti- . avoid swimming pools and spa centres whilst ill and microbial resistance in the population. Transmission of for two weeks after recovery (level IV, grade C). ciprofloxacin-resistant S. sonnei, among MSM in Montreal, Que´bec, has been reported.31 Therapy, partner notification and follow-up. Partner notification: The possible source of infection should be ascertained if possible, in the know- Rectal gonorrhoea ledge that many infected individuals are symptomless. Sexual partners within the week preceding the onset of Patient management should follow that recommended for symptoms should be screened for infection. In case of anogenital gonorrhoea (see 2012 European Guideline on shigella and salmonella infections, symptomatic house- the Diagnosis and Treatment of Gonorrhoea in Adults: hold contacts should be identified, notified and further http://www.iusti.org/regions/Europe/euroguideli- managed in a healthcare setting. nes.htm). Concurrent treatment for chlamydial infection Public health authority notification: Some of the should also be given unless this infection has been mentioned enteric infections (e.g. shigella, shiga- excluded by microbiological testing (level III, grade C). toxin producing E. coli, hepatitis A) are notifiable diseases. Please check with your national public health Rectal chlamydial infection (non-LGV) authority. Follow-up: This is usually unnecessary, but in the Patient management should follow that recommended case of food handlers/medical staff/nurses/day care lea- for rectal chlamydia (see European guideline for the man- ders with shigellosis, local regulations may apply before agement of Chlamydia trachomatis infections: http:// they are allowed back to work. Please check with your www.iusti.org/regions/Europe/euroguidelines.htm). national public health authority.

Rectal LGV Amoebiasis Patient management should follow that recommended Therapy: Metronidazole given in an oral dose of for anorectal LGV (see 2013 European Guideline on 750 mg three times daily for 5 to 10 days is the

Downloaded from std.sagepub.com by guest on May 16, 2014 470 International Journal of STD & AIDS 25(7) drug of first choice (level IIa, grade A). Cryptosporidiosis and microsporidiosis Alternatively, tinidazole given in a singe daily dose of 2 g by mouth for 2–3 days may be used (level IIb, Therapy: In the immunocompetent patient, the con- grade A). This therapy should be followed by a dition is self-limiting. There is no reliable anti-proto- intraluminal agent like Paromomycin 10 mg/kg/day zoal agent for the treatment of cryptosporidiosis in three times daily for 5–10 days or Diloxanide furo- HIV-infected patients. However, initiation of ate given orally in a dose of 500 mg three times HAART is often helpful (level III, grade B) and daily for 10 days or Clioquinol 250 mg three times Paromomycin 500 mg tid for 7 days can be tried (level daily for 10 days to eliminate all infection from the IV, grade C). bowel (level IIa, grade B). Partner notification: The value of partner notifica- Partner notification: In the case of the individual tion in patients with cryptosporidiosis is uncertain. In who has not travelled to an endemic area, partner noti- immunocompetent individuals it is a self-limiting con- fication should be undertaken. All partners within the dition and there is no definitive treatment. It is doubtful preceding 3–4 months should be assessed (level IV, if contact tracing would reduce the risk of onward grade C). transmission. Follow-up: In the case of food handlers with amoeb- Follow-up: In the immunocompetent patient this is iasis local regulations may apply before they are unnecessary. allowed back to work. Please check with your national public health authority. Non-specific proctitis

Cytomegalovirus Therapy: Syndromic treatment awaiting definite microbiological results: Therapy: Although the role of antiviral therapy in primary CMV proctitis has not been defined, it is . doxycycline 100 mg twice daily by mouth for seven probably not essential in all cases, as most reported days cases resolved spontaneously without complica- tions.21 Reported cases associated with acute HIV Partner notification: Not required if no pathogens co-infection resolved upon immune restoration, with- are found. out antiviral therapy. On the other hand, CMV col- Follow-up: Not necessary. itis in immunosuppressed or HIV-infected patients may be progressive, is associated with high mortal- Syndromic management of the patient ity, and requires antiviral treatment with (val) ganciclovir. with anorectal and/or intestinal symptoms Partner notification: not required. in whom a sexually transmissible cause is Follow-up: In the immunocompetent patient this is suspected unnecessary. History

Giardiasis A consideration of the patient’s symptoms (see above) is often helpful in determining whether the patient has Therapy: proctitis, proctocolitis or enteritis. A sexual history is, of course, important. . Metronidazole given by mouth in a dosage of 2 g Among HIV-infected patients, gastrointestinal ill- daily for 3 days; ness can be caused by other infections that usually are . 500 mg two times per day for 5 days is the most not sexually transmitted, including CMV, commonly used treatment (level IIa, grade B) or; Mycobacterium avium–intracellulare, Salmonella spp., . Tinidazole in a single oral dose of 2 g is an alterna- Campylobacter spp., Shigella spp., Cryptosporidium, tive (level IIa, grade B). Microsporidium and Isospora.32 In addition, enteritis can be directly caused by HIV infection. Partner notiﬁcation: As the infected sexual partner is often symptomless, partner notiﬁcation should be Physical examination and diagnostic tests undertaken in all cases. All partners of patients with symptomatic infection within the preceding month Palpate the abdomen: Tenderness over the colon sug- should be assessed. gests colitis. Follow-up: In the immunocompetent patient this is Inspect the perianal region: Perianal ulceration may unnecessary (level IV, grade C). suggest syphilis, HSV infection or LGV.

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Figure 1. Syndromic management flow chart for patients in whom an anorectal sexually transmissible infection is suspected. *Perform a full HIV/STI screening (including hepatitis B and C testing and hepatitis B vaccination). Ct: C. trachomatis; Ng: N. gonorrhoeae; HSV: Herpes simplex virus; LGV: Lymphogranuloma venereum; PMNL: Polymorphonuclear leucocytes; Tp: T. pallidum.

If proctitis is suspected, proctoscopy should be per- This usually allows differentiation between a distal formed to inspect for mucosal inflammation and infil- proctitis and a proctocolitis and will inform on a tration/swelling and/or ulceration (Figure 1). rational treatment choice. If possible, stained smears (preferably Gram) of rectal exudate should be made and the number of polymorphs in light microscopic high-power field Treatment (magnification, 1000) noted; > 10 cells suggests proctitis.33 If Gram-negative diplococci are seen Specific treatment: In the case of patients with mild within the cytoplasm of neutrophilic granulocytes, a symptoms, and when microbiological investigations presumptive diagnosis of rectal gonorrhoea may be are possible, it is best to await the results of these made. Ideally, microbiological tests for the various tests before initiating specific therapy. infections detailed above should be taken. When Syndromic treatment: In patients with more severe facilities for organism-specific diagnosis of an STI symptoms, or when microbiological testing is impos- are unavailable or limited, or when a syndromic sible, or if there are persistent symptoms and signs treatment approach is considered imperative, rigid but microbiological tests are negative, or if the patient sigmoidoscopy should be undertaken, if available. is unable to attend when test results are available,

Downloaded from std.sagepub.com by guest on May 16, 2014 472 International Journal of STD & AIDS 25(7) syndromic treatment (empirical therapy) should be Acknowledgement given: The authors thank David Kwa, MD, PhD, and physician- Proctitis: doxycycline 100 mg twice daily by mouth microbiologist and Dr. Miruna David, microbiologist, for for seven days34; critically reviewing and commenting on the draft manuscript. PLUS: ceftriaxone 500 mg as single intramuscular injection (especially if anorectal gonorrhoea is Conflict of interest suspected); The authors declare no conflict of interest. PLUS: valaciclovir 500 mg given orally twice daily for 5–10 days (especially if anorectal HSV infection is suspected); or acyclovir 400 mg three times daily for 5– Funding 10 days. This research received no specific grant from any funding PLUS: benzathine penicillin 2.4 million units i.m. (if agency in the public, commercial, or not-for-profit sectors. rapid diagnostic tests are supportive of the diagnosis of early syphilis); or doxycycline 100 mg twice daily by References mouth for 14 days. 1. Tian LH, Peterman TA, Tao G, et al. Heterosexual anal sex activity in the year after an STD clinic visit. Sex Proctocolitis Transm Dis 2008; 35: 905–909. 2. Mayer KH. Sexually transmitted diseases in men who If the patient has recently visited a geographical area have sex with men. Clin Infect Dis 2011; 53: S79–S83. where amoebiasis is prevalent, or if he or she is a sexual 3. Goodgame RW. Gastrointestinal cytomegalovirus dis- contact with a person who has returned from such an ease. Ann Int Med 1993; 119: 924–935. area, consider amoebiasis. Presumptive treatment may 4. Quinn TC, Stamm WE, Goodell SE, et al. The polymi- be considered with: crobial origin of intestinal infections in homosexual men. N Engl J Med 1983; 309: 576–582. . Metronidazole 750 mg tid for 5–10 days (level IV, 5. Edlund M, Blaxhult A and Bratt G. The spread of Mycoplasma genitalium among men who have sex with grade C). men. Int J STD AIDS 2012; 23: 455–456. 6. Francis SC, Kent CK, Klausner JD, et al. Prevalence of rectal Trichomonas vaginalis and Mycoplasma genitalium Enteritis in male patients at the San Francisco STD clinic, 2005- 2006. Sex Transm Dis 2008; 35: 797–800. In cases associated with bacterial pathogens, fluid 7. Palella FJ Jr, Delaney KM, Moorman AC, et al. replacement is the most important aspect of treatment. Declining morbidity and mortality among patients with When symptoms are severe, antimicrobial therapy may advanced human immunodeficiency virus infection. N be required. Presumptive treatment may be considered Engl J Med 1998; 338: 853–860. with: 8. Scholefield JH, Harris D and Radcliffe A. Guidelines for Ciprofloxacin 500 mg twice daily by mouth for management of anal intraepithelial neoplasia. Colorectal Dis 5 days (or co-trimoxazole 960 mg twice daily for 2011; 13: 3–10. 9. de Vrieze NH, van Rooijen M, van der Loeff MF, et al. 7 days or azithromycin 500 mg once daily for Anorectal and inguinal lymphogranuloma venereum 3 days). among men who have sex with men in Amsterdam, the Failure to respond symptomatically within four Netherlands: trends over time, symptomatology and con- weeks should prompt further investigations by a current infections. Sex Transm Infect 2013; 89: 548–552. gastroenterologist. 10. Aragoń TJ, Vugia DJ, Shallow S, et al. Case-control study of shigellosis in San Francisco: the role of sexual transmission and HIV infection. Clin Infect Dis 2007; 44: Patient Information 327–334. A patient information leaflet based on this guideline is 11. Arnold CA, Limketkai BN, Illei PB, et al. Syphilitic and available at www.iusti.org. lymphogranuloma venereum (LGV) proctocolitis: clues Proposed review date to a frequently missed diagnosis. Am J Surg Pathol 2013; 37: 38–46. April, 2018 12. Mistrangelo M, Dal Conte I, Gregori G, et al. Rectal European STI Guidelines Editorial Board lymphogranuloma venereum. Colorectal Dis 2012; 14: See http://www.iusti.org/regions/Europe/euroguide- e792–e793. lines.htm 13. Soni S, Srirajaskanthan R, Lucas SB, et al. List of contributing organisations Lymphogranuloma venereum proctitis masquerading as See www.iusti.org/regions/Europe/euroguidelines. inflammatory bowel disease in 12 homosexual men. htm Aliment Pharmacol Ther 2010; 32: 59–65.

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literature of overall good quality and consistency . C (Evidence IV) Requires evidence from expert addressing the speciﬁc recommendation. committee reports or opinions and/or clinical experi- . B (Evidence levels IIa, IIb, III) Requires availabil- ence of respected authorities. Indicates absence of ity of well-conducted clinical studies but no rando- directly applicable studies of good quality. mised clinical trials on the topic of recommendation.

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